Melioidosis is a frequently lethal tropical infection caused by the environmental saprophyte Burkholderia pseudomallei. Although transcutaneous inoculation and inhalation are considered the primary routes of infection, suggestive clinical evidence implicates ingestion as a possible alternative route. We show that in BALB/c and C57BL/6 mice, direct gastric inoculation of high doses of B. pseudomallei causes systemic infection that may be lethal or cause chronic disseminated infection. Mice may shed bacteria in the stool for weeks after infection, and high titers of B. pseudomallei-specific IgG are detectable. This report of enteric murine melioidosis supports further consideration of this route of infection.

Structured observation is often used to evaluate handwashing behavior. We assessed reactivity to structured observation in rural Bangladesh by distributing soap containing acceleration sensors and performing structured observation 4 days later. Sensors recorded the number of times soap was moved. In 45 participating households, the median number of sensor soap movements during the 5-hour time block on pre-observation days was 3.7 (range 0.3–10.6). During the structured observation, the median number of sensor soap movements was 5.0 (range 0–18.0), a 35% increase, P = 0.0004. Compared with the same 5-hour time block on pre-observation days, the number of sensor soap movements increased during structured observation by ≥ 20% in 62% of households, and by ≥ 100% in 22% of households. The increase in sensor soap movements during structured observation, compared with pre-observation days, indicates substantial reactivity to the presence of the observer. These findings call into question the validity of structured observation for measurement of handwashing behavior.

Aflatoxins are fungal metabolites that contaminate staple food crops in many developing countries. Up to 40% of women attending a prenatal clinic in Africa may be anemic. In a cross-sectional study of 755 pregnant women, Aflatoxin B1-lysine adducts (AF-ALB) levels were determined by high-performance liquid chromatography. Participants were divided into quartiles “low,” “moderate,” “high,” and “very high.” Anemia was defined as hemoglobin levels < 11 g/dL. Logistic regression was used to examine the association of anemia with AF-ALB. The mean AF-ALB level was 10.9 pg/mg (range = 0.44–268.73 pg/mg); 30.3% of participants were anemic. The odds of being anemic increased 21% (odds ratio [OR], 1.21, P = 0.01) with each quartile of AF-ALB reaching an 85% increased odds in the “very high” compared with the “low” category (OR, 1.85; confidence interval [CI], 1.16–2.95). This association was stronger among women with malaria and findings were robust when women with evidence of iron deficiency anemia were excluded. This study found a strong, consistent association between anemia in pregnancy and aflatoxins.

Our objective was to characterize both epidemiologically and clinically manifestations after severe scorpion envenomation and to define simple factors indicative of poor prognosis in children. We performed a retrospective study over 13 years (1990–2002) in the medical intensive care unit (ICU) of a university hospital (Sfax-Tunisia). The diagnosis of scorpion envenomation was based on a history of scorpion sting. The medical records of 685 children aged less than 16 years who were admitted for a scorpion sting were analyzed. There were 558 patients (81.5%) in the grade III group (with cardiogenic shock and/or pulmonary edema or severe neurological manifestation [coma and/or convulsion]) and 127 patients (18.5%) in the grade II group (with systemic manifestations). In this study, 434 patients (63.4%) had a pulmonary edema, and 80 patients had a cardiogenic shock; neurological manifestations were observed in 580 patients (84.7%), 555 patients (81%) developed systemic inflammatory response syndrome (SIRS), and 552 patients (80.6%) developed multi-organ failure. By the end of the stay in the ICU, evolution was marked by the death in 61 patients (8.9%). A multivariate analysis found the following factors to be correlated with a poor outcome: coma with Glasgow coma score ≤ 8/15 (odds ratio [OR] = 1.3), pulmonary edema (OR = 2.3), and cardiogenic shock (OR = 1.7). In addition, a significant association was found between the development of SIRS and heart failure. Moreover, a temperature > 39°C was associated with the presence of pulmonary edema, with a sensitivity at 20.6%, a specificity at 94.4%, and a positive predictive value at 91.7%. Finally, blood sugar levels above 15 mmol/L were significantly associated with a heart failure. In children admitted for severe scorpion envenomation, coma with Glasgow coma score ≤ 8/15, pulmonary edema, and cardiogenic shock were associated with a poor outcome. The presence of SIRS, a temperature > 39°C, and blood sugar levels above 15 mmol/L were associated with heart failure.

Edema, parasthesias, and paresis affected 10 residents of an Indian community in Roraima state; three died. Mining with mercury occurs locally; caxirí, a traditional alcoholic drink, is consumed daily. We conducted a 1:2 unmatched case-control study; a case was an Indian from Uiramutã county (population of 9,127) who presented ≥ 1 of lower extremity edema, paresthesias, paresis, or weakness. Controls were asymptomatic Indians randomly selected from the population. We identified 90 cases (prevalence of 1%) and 180 controls; all were enrolled. Among cases, 79% were male, and the median age was 31 years. Ethnicity was Macuxí, and 49% had income. Cases had lower extremity edema (85%), upper extremity paresthesias (84%), and lower extremity weakness and pain (78%). Risk factors were male sex (odds ratio [OR] = 6.8; P < 0.001), age 31–40 years (OR = 5.63; P < 0.001), and consumption of caxirí (OR = 2.7; P < 0.003). Mercury exposure was not a risk. Thiamine therapy produced complete rapid clinical recovery in all cases, confirming the diagnosis of beriberi. We recommend surveillance, thiamine supplementation, and nutritional intervention.

Restaveks, or indentured foster children, are a poorly understood, vulnerable subclass of Haitian society. From 2001 to the present, a partnership between multiple US academic medical centers and Project Medishare for Haiti has held an ongoing series of mobile clinics in rural Haiti. Multiple cases of restavek-related illness were identified. At a recent pair of mobile clinics, the authors identified two restavek cases that were significantly worse off than their communal peer groups and required immediate care. Given the lack of a robust legal support to protect orphaned children in Haiti, clinicians have an important role in advocating for restaveks at the bedside. The plight of Haiti's restaveks is widely reported in the human rights literature but is not publicly recognized as an issue for community health and wellbeing among physicians. To address these health disparities, the health consequences of an entire class of neglected children must be further explored.

The clays consumed by geophagous individuals contain large quantities of aluminum, a known neurological and hematological toxin. This is the first study to evaluate the risk of aluminum poisoning in geophagous individuals. Blind determinations of plasma and urinary aluminum concentrations were carried out in 98 anemic geophagous pregnant women and 85 non-anemic non-geophagous pregnant women. Aluminum concentrations were significantly higher (P < 0.0001) in the geophagous anemic women than in the controls, with odds ratios of 6.83 (95% confidence interval [CI] = 2.72–19.31) for plasma concentrations (13.92 ± 14.09 μg/L versus 4.95 ± 7.11 μg/L) and 5.44 (95% CI = 2.17–14.8) for urinary concentrations (92.83 ± 251.21 μg/L versus 12.11 ± 23 μg/L). The ingested clay is the most likely source of this overexposure to aluminum. If confirmed, the clinical consequences of this absorption for pregnant women and their offspring should be explored.

The objective was to assess the association of enteric pathogens in diarrheal disease in a remote rural area in Thailand. Stool specimens were collected from 236 children aged 3 months to 5 years with acute diarrhea (cases) and from 236 asymptomatic controls. Standard microbiologic methods, and enzyme immunoassay for viral pathogens, Giardia, and Cryptosporidium, were used to identify enteric pathogens with susceptibility testing by disk diffusion. Campylobacter, Plesiomonas, Salmonella, and enterotoxigenic Escherichia coli were commonly isolated from cases and controls (22% versus 25%, 10% versus 11%, 6% versus 9%, and 10% versus 6%, respectively). Only Shigella, rotavirus, and adenovirus were identified significantly more frequently in cases than controls (9% versus 0%, 18% versus 3%, and 16% versus 2%, respectively), whereas Giardia lamblia was detected less often in cases than controls. Most pre-school children were infested with enteric pathogens; laboratory-based studies are important to understand the epidemiology of enteric pathogens in remote areas among marginal populations.

Cryptosporidium is a leading cause of childhood diarrhea in developing countries. We investigated symptomatic and asymptomatic cryptosporidiosis in 20 children less than two years of age in a semi-urban slum in southern India. All surveillance (conducted every two weeks) and diarrheal samples from 20 children (n = 1,036) with cryptosporidial diarrhea previously identified by stool microscopy were tested by polymerase chain reaction–restriction fragment length polymorphism for species and subgenotype determination. Thirty-five episodes of cryptosporidiosis were identified in 20 children, of which 25 were diarrheal. Fifteen episodes were associated with prolonged oocyst shedding. Multiple episodes of cryptosporidiosis occurred in 40% of the children. Most infections were with C. hominis, subtype Ia. Children with multiple infections had significantly lower weight-for-age and height-for-age Z scores at 24 months but had scores comparable with children with a single episode by 36 months. Multiple symptomatic Cryptosporidium infections associated with prolonged oocyst shedding occur frequently in this disease-endemic area and may contribute to the long-term effects of cryptosporidiosis on physical growth in these children.

Microsporidiosis often occurs in immunocompromised persons but may also occur in those who are immunocompetent. Infection by Microsporidia involves a variety of organs and systems, most notably, intestine, lung, kidney, brain, sinuses, muscle, and eyes. Enterocytozoon bieneusi and Encephalitozoon intestinalis are associated with gastroenteritis, and Enterocytozoon hellem and Encephalitozoon cuniculi are associated with keratoconjunctivitis. We report a case of chronic microsporidiosis in a 28-year-old woman missionary from Mozambique who came to our diagnostic laboratory with nausea, lower abdominal pain, and frequent bowel movements. Over two years, the patient was clinically assessed and treated for malaria and giardiasis without laboratory diagnosis while in Mozambique. Identification of the causative agent of her condition was not attempted during the course of her illness in Mozambique. Furthermore, adverse effects of malaria and giardiasis medications may have exacerbated the chronic illness in this patient and mimicked chronic microsporidiosis.

Whether the exceptionally low prevalence of Helicobacter pylori (HP) infection reported among Malays is also present among aborigines (the Orang Asli) living in northeastern Peninsular Malaysia is unknown. We studied asymptomatic Orang Asli from settlements situated 210 km from the city of Kota Bharu. The HP infection status was confirmed by a validated serology test. Nineteen percent of 480 Orang Asli tested positive for HP infection. The prevalence was 40.6% in the birth cohort of the 1940s and declined steadily in later cohorts to under 10% among 12–30 year olds. This may be related to the phases of relocation from the jungles into resettlement camps and ultimately into designated villages near rivers. The low prevalence pattern after the 1970s was probably partly a result of improvement in sanitation and hygiene practice in these villages but other unidentified factors may also be operating.

Aeromonas species are Gram-negative bacilli of the water environment whose survival appears facilitated by warm climates. There have been no reports on Aeromonas hydrophila complex (A. hydrophila, A. caviae, A. veronii) in the Caribbean to date. Our aim was to describe clinical and bacteriological features in patients presenting with such bacteremia in Martinique and Guadeloupe. During a 14-year period, we retrospectively identified 37 patients. The mean age was 55 years and in 89% of cases underlying disease such as digestive diseases, cutaneous wounds, and malignancy were identified. One case was related to severe strongyloidiasis and one with snake bite. Polymicrobial bacteremia was identified in 38%, essentially with Enterobacteriaceae. All Aeromonas isolates were resistant to amoxicillin but extended-spectrum beta-lactam and fluoroquinolone were active against more than 95%. During hospitalization 10 patients died (27%). Older age, occurrence of multiorgan failure, and impaired renal function were associated with in-hospital mortality.

Since February 2002, the Drug Resources Enhancement against AIDS and Malnutrition Program has provided highly active antiretroviral therapy (HAART) and immunologic and virologic monitoring free of charge. We conducted a cohort study of persons infected with human immunodeficiency virus in Mozambique. Only persons treated with HAART with available CD4 cell counts at baseline and ≥ 1 CD4 cell count after HAART were included. Survival analysis was applied to evaluate the prognostic value of CD4 cell counts measured at three months. Possible confounders were considered. A total of 753 persons who started HAART included; 59% were females. Median age was 34 years (range = 16–67 years), and the median CD4 cell count at baseline was 172 cells/mm3 (interquartile range = 87–261 cells/mm3, range = 0–1,322 cells/mm3). Overall, 105 persons (14%) died. Of these persons 54 (51%) developed AIDS before they died; 25 (3%) died during the first three months. After three months of therapy, the individual median CD4 cell count change from the baseline value was +101 cells/mm3 (interquartile range = +27 to +187 cells/mm3, range = –723 to +310 cells/mm3). A median CD4 increment of 100 cells/mm3 in three months was associated with a mortality reduction of 50% compared with an increase of < 50 cells (relative hazard of death adjusted for baseline CD4 cell count = 0.54, 95% confidence interval = 0.30–0.95). A good initial response to HAART was associated with a significant reduction of mortality. This finding supports the effectiveness of HAART in resource-poor settings.

Prognosis varies among persons with West Nile virus (WNV) infection, but the most important factors associated with persistent symptoms are not clear. In this cross-sectional study, 265 persons with symptomatic WNV infection during 2006–2008 completed a survey a mean of 7.7 months after diagnosis. We determined the association of demographic and clinical characteristics to the most common symptoms. Of 214 persons infected ≥ 6 months, 53% reported one or more persistent symptoms, including fatigue, muscle aches, decreased activity, difficulty with memory, and difficulty concentrating. Persons with neuroinvasive disease, hypertension, or diabetes were significantly more likely to report persistent symptoms, whereas age, sex, and time since infection were not associated with persistent symptoms. In conclusion, persistent symptoms persisted in most persons for more than six months after symptomatic WNV infection. Improved strategies for prevention and treatment are needed.

In Los Angeles, California, West Nile virus (WNV) has followed a pattern of emergence, amplification, subsidence, and resurgence. A time series cross-correlation analysis of human case counts and sentinel chicken seroconversions revealed temporal concordance indicating that chicken seroconversions tracked tangential transmission of WNV from the basic passeriform-Culex amplification cycle to humans rather than antecedent enzootic amplification. Sentinel seroconversions provided the location and time of transmission as opposed to human cases, which frequently were reported late and were assumed to be acquired 2–14 days before disease onset at their residence. Cox models revealed that warming degree-days were associated with the increased risk of seroconversion, whereas elevated herd immunity in peridomestic birds dampened seroconversion risk. Spatially, surveillance data collected within a 5 km radius of flock locations 15–28 days before the bleed date were most predictive of a seroconversion. In urban Los Angeles, sentinel chicken seroconversions could be used as an outcome measure in decision support for emergency intervention.

We evaluated performance of three commercial Japanese encephalitis virus (JEV) IgM antibody capture enzyme-linked immunosorbent assay (MAC ELISA) kits with a panel of serological specimens collected during a surveillance project of acute encephalitis syndrome in India and acute meningitis and encephalitis syndrome in Bangladesh. The serum and cerebral spinal fluid specimens had been referred to the Centers for Disease Control and Prevention (CDC) for confirmatory testing. The CDC results and specimen classifications were considered the reference standard. All three commercial kits had high specificity (95–99.5%), but low sensitivities, ranging from 17–57%, with both serum and cerebrospinal fluid samples. Specific factors contributing to low sensitivity compared with the CDC ELISA could not be determined through further analysis of the limits and dilution end points of IgM detection.

Comparative sequence analysis was performed on the full-length genomic sequences of 10 representative dengue virus serotype 1 (DENV-1) strains sampled from patients at Children's Hospital, Bangkok, Thailand over a 22-year period, which represented different epidemics, disease severity, and sampling time. The results showed remarkable inter-genotypic variation between predominant and non-predominant genotypes and genotype-specific amino acids and nucleotides throughout the entire viral genome except for the 5′-non-translated region. The frequency of intra-genotypic variation was correlated with dengue transmission rate and sampling time. The 5′-non-translated region of all 10 viruses was highly conserved for predominant and non-predominant genotypes and NS2B was the most conserved protein. Some intra-genotypic substitutions of amino acids and nucleotides in predominant genotype strains were fixed in the viral genome since 1994, which indicated that the evolution of predominant genotype strains in situ over time might contribute to increased virus fitness important for sustaining dengue epidemics in Thailand.

A large-scale cross-sectional seroprevalence study of dengue (DEN) and Japanese encephalitis (JE) was conducted in Khammouane province, Lao PDR, as part of the initial baseline health impact assessment of the Nam Theun 2 hydroelectric dam construction project. Health surveys were performed between May 2007 and February 2008 with serum samples collected from healthy individuals involved in the resettlement program of 16 villages (total surveyed population 4,369). Hemagglutination inhibition assay using flavivirus antigens (DENV1, DENV3, and JEV) performed on 1,708 plasma specimens revealed 30.4% (519) cross-reactive positives, and 10% (172) and 1.3% (22) positives to JEV or DENV, respectively. Entomological surveys conducted during the rainy season of 2008 indicated the presence of competent flavivirus vectors (Culex vishnui group and Aedes albopictus), although Aedes aegypti was not found. Continued surveillance and investigation is warranted to assess the clinical disease burden of flaviviruses in this area that is undergoing rapid ecological and demographic change.

An outbreak of hepatitis E virus (HEV) began in October 2007 in northern Uganda. To determine risk factors and sources for ongoing transmission, we conducted both a case-control study and an environmental investigation. A case patient was defined as having serologic evidence of HEV infection, whereas controls were seronegative. We identified risk factors for infection by univariable and multivariable analyses using conditional logistic regression. Several water sources were tested for HEV RNA. Among 112 cases and 145 controls, storage of drinking water in large-mouthed vessels (adjusted odds ratios [AOR] = 2.83; 95% confidence interval [CI] = 1.16–6.94) and washing hands in a group basin (AOR = 1.90; 95% CI = 1.07–3.38) were associated with HEV infection. HEV RNA was detected from communal hand-rinse and surface-water samples. The epidemiologic and environmental water-testing results suggest that household-level factors played an important role in the transmission of HEV—modalities that have been previously underappreciated.